Stop routine pelvic exams, doctors group says

Women, here's one thing one group of doctors says you can scratch from your annual to-do list: the routine pelvic exam.

The long-standing ritual – which requires a woman to lie on an exam table and put her feet in stirrups for an external and internal exam of her genitals and reproductive organs – has no known benefits when it is performed on symptom-free women who are not pregnant, says the American College of Physicians. The exam should be dropped from routine care, the internists group says in Monday's Annals of Internal Medicine.

"There's a pretty long list of potential harms," including fear, embarrassment, pain and costly, unneeded care when abnormalities found on the exam -- such as uterine fibroids and ovarian cysts -- turn out to be harmless, says Linda Humphrey, a specialist in preventive medicine at the Portland VA Medical Center in Oregon.

Humphrey is among authors of the recommendation. It is based on an evidence review that found no studies supporting the pelvic exam for finding ovarian cancer or any other serious disease. The review found some studies suggesting the exam causes distress in up to 80% of women.

The recommendation already is raising controversy. Some doctors applaud it and others say it could set back preventive health care for women.

It also may cause some confusion: It does not apply to women with pelvic pain, abnormal bleeding, sexual dysfunction or other symptoms. And it's not about Pap smears, the screening test for cervical cancer in which a doctor collects a sample of cells from a woman's cervix. All major medical groups continue to recommend Pap smears, though no more often than every three years.

Instead, it's about what doctors do 63 million times a year whether women are getting Paps or not: a visual inspection of the outer genitals, the placing of a speculum to view the vagina and cervix, and then a two-handed internal and external exam to feel for abnormalities in the uterus and ovaries.

Another doctors' group, the American College of Obstetricians and Gynecologists (ACOG) continues to recommend an annual pelvic exam for all women over age 21 – but also acknowledges lack of strong evidence for or against the practice. It says the exam is not needed to screen for sexually transmitted diseases or to prescribe birth control pills. In a formal 2012 opinion and in a statement Monday, the group said doctors and patients should make a "shared decision" about whether the exam is worthwhile.

"The exam has value," for many women who see gynecologists for routine care, says Barbara Levy, ACOG's vice president for health policy. For one thing, she says, women often don't bring up symptoms such as pelvic pain until a doctor finds an abnormality. She says many women also find reassurance when a doctor can tell them that their genitals and reproductive organs are healthy and normal.

Eliminating the exam would mean "providing women with less comprehensive care," says Taraneh Shirazian, assistant professor of obstetrics, gynecology and reproductive science at the Icahn School of Medicine at Mount Sinai, New York. ​

But even some gynecologists are questioning the exam. It "has become more of a ritual than an evidence-based practice," says an editorial accompanying the recommendation, written by George Sawaya, associate professor in obstetrics, gynecology and reproductive sciences at the University of California San Francisco Medical Center.

Ranit Mishori, a specialist in family medicine and an associate professor of medicine at Georgetown University School of Medicine in Washington, D.C., says she is convinced the routine pelvic exam "has very little to no value for patients," so she does not offer it.

Some women worry about skipping it, she says. "But many are very happy to hear this…I know there are women who avoid doctors' appointments because they don't want to undergo this exam."